Cirrhosis

Question 1

Define cirrhosis

Answer 1

End stage of chronic liver damage w/ replacement of normal liver architecture w/ diffuse fibrosis & nodules of regenerating hepatocytes

Question 2

Decompensated cirrhosis if complicated by:

4

Answer 2

Ascites
Jaundice
Encephalopathy
GI bleed

Question 3

Decompensated cirrhosis can be precipitated by:

8

Answer 3

Infection
GI bleed
Constipation
High protein meal 
Electrolyte imbalance
Alcohol & drugs
Tumour development 
Portal vein thrombosis

Question 4

Causes of cirrhosis

9

Answer 4

Chronic alcohol misuse
Chronic viral hepatitis (Hep B/C)
Autoimmune hepatitis
Drugs (e.g. methotrexate, hepatotoxic drugs)
Inherited
Vascular
Chronic biliary diseases (PBC, PSC, biliary atresia)
Unknown (5-10%)
Non-alcoholic steatohepatitis (NASH

Question 5

Causes of cirrhosis - inherited

5

Answer 5

α1-antitrypsin deficiency
Haemochromatosis 
Wilson’s disease
Galactosaemia
Cystic fibrosis

Question 6

Causes of cirrhosis - vascular

2

Answer 6

Budd-Chiari syndrome

Hepatic venous congestion

Question 7

NASH associated w/

6

Answer 7

obesity
diabetes
total parenteral nutrition
short bowel syndromes
hyperlipidaemia 
drugs (e.g. amiodarone, tamoxifen)

Question 8

Epidemiology of cirrhosis

death, most common cause UK + world

Answer 8

1 of the top 10 causes of death world wide

Most common cause in UK - chronic alcohol misuse
Most common cause worldwide - chronic viral hepatitis

Question 9

Presenting symptoms of cirrhosis

4 categories

Answer 9

Early non specific
Due to decreased liver synthetic function
Due to reduced detoxification function
Due to portal hypertension

Question 10

Presenting symptoms of cirrhosis - early non specific

5

Answer 10

Anorexia 
Nausea
Fatigue 
Weakness
Weight loss

Question 11

Presenting symptoms of cirrhosis - decreased liver synthetic function
(3)

Answer 11

Easy bruising
Abnormal swelling
Ankle oedema

Question 12

Presenting symptoms of cirrhosis - reduced detoxification function
(5)

Answer 12

Jaundice
Personality change 
Altered sleep pattern
Amenorrhoea
Galactorrhoea

Question 13

Presenting symptoms of cirrhosis - portal hypertension

3

Answer 13

Abdominal swelling
Haematemesis
PR bleeding or melaena

Question 14

Signs of cirrhosis on physical examination

16

Answer 14

Asterixis 
Bruises
Clubbing 
Dupuytren’s contracture
Palmar erythema
Jaundice
Gynaecomastia
Leukonychia
Parotid enlargement
Spider naevi
Scratch marks (from cholestatic pruritus)
Ascites
Enlarged liver 
Testicular atrophy
Caput medusae
Splenomegaly

Question 15

Investigations for cirrhosis

7

Answer 15

Bloods
Investigations to determine cause
Ascitic tap
Liver biopsy
Imaging
Endoscopy
Child-Pugh grading

Question 16

Investigations for cirrhosis - bloods

4

Answer 16

FBC
low platelets & Hb
LFTs
may be normal but often:
high AST, ALT, ALP, GGT, bilirubin & low albumin
Clotting 
prolonged PT
Serum AFP
raised in chronic liver disease
high levels may suggest hepatocellular carcinoma

Question 17

Investigations for cirrhosis - cause

6

Answer 17

Viral serology
α1-antitrypsin
Caeruloplasmin (Wilson’s disease)
Iron studies - serum ferritin, iron, total iron binding capacity TIBC (for haemochromatosis) 
Anti-mitochondrial antibody  (PBC)
ANA, ASMA (autoimmune hepatitis)

Question 18

Investigations for cirrhosis - ascitic tap

4

Answer 18

MC&S - check for infection
Biochem (protein, albumin, glucose, amylase)
Cytology
Neutrophils >250/mm^3 = spontaneous bacterial peritonitis (SBP)

Question 19

Investigations for cirrhosis - liver biopsy

4

Answer 19

Performed percutaneously or transjugular (if totting deranged or ascitic)
Histopathological features of cirrhosis
periportal fibrosis
loss of normal liver architecture
nodular appearance
Grade - indicates degree of inflammation
Stage - degree of architectural distortion (mild portal fibrosis —> cirrhosis)

Question 20

Investigations for cirrhosis - imaging

3

Answer 20

US, CT, MRI
To detect complications e.g.: ascites, HCC, hepatic/portal vein thrombosis, exclude biliary obstruction
MRCP (if PSC suspected)

Question 21

Investigations for cirrhosis - endoscopy

Answer 21

To examine varices

Question 22

Investigations for cirrhosis - Child-Pugh grading

8

Answer 22

= score for estimating prognosis in chronic liver disease/cirrhosis

Based on:
Albumin
Bilrubin
PT
Ascites
Encephalopathy 

Class A = 5-6
Class B = 7-9
Class C = 10-15

Question 23

Management of cirrhosis - general

5

Answer 23

Treat cause if possible
Avoid alcohol, sedatives, opiates, NSAIDS & drugs that affect liver
Nutrition important
Enteral supplements should be given
NG feeding may be indicated

Question 24

Management of cirrhosis - complications (encephalopathy)

4

Answer 24

Treat infections
Exclude GI bleed
Lactulose & phosphate enemas
Avoid sedation

Question 25

Management of cirrhosis - complications (ascites)

6

Answer 25

Diuretics (spironolactone w/w/o furosemide)
Dietary sodium restrictions
Therapeutic paracentesis (w/ human albumin replacement)
Monitor weight
Fluid restrict if plasma sodium <120mmol/L
Avoid alcohol & NSAIDS

Question 26

Management of cirrhosis - complications (SBP)

2

Answer 26

Antibiotics (e.g. cefuroxime & metronidazole)

Prophylaxis against recurrent SBP w/ ciprofloxacin

Question 27

Management of cirrhosis - complications (surgical)

2

Answer 27

Consider TIPS (transjugular intrahepatic portosystemic shunt) to help reduce portal hypertension 
Liver transplant is only curative method

Question 28

Complications of cirrhosis

7

Answer 28

Portal hypertension w/ ascites
Hepatic encephalopathy
Variceal haemorrhage
SBP
HCC 
Renal failure (hepatorenal syndrome)
Pulmonary hypertension (hepatopulmonary syndrome)

Question 29

Prognosis of cirrhosis

general + 2

Answer 29

Depends on aetiology & complications
Generally poor prognosis
50% 5 yr survival
50% 2 yr survival if ascites